Jun. 13, 2013

Greg Hunt has diabetes, Addison's Disease, a thyroid condition – and no health insurance. The Kent County man works and goes to school, but he has had to defer purchase of a prescription due to cost and has had major health bills that have gone unpaid. / Lance Wynn/Bridge Magazine

Written by

Ted Roelofs

For Bridge Magazine

colleenzanotti

But, in the back of his mind, the 25-year-old Kent County resident knows he is one health crisis removed from thousands of dollars in medical bills he can’t pay. Given that he has Addison’s disease, a chronic endocrine disorder, an overactive thyroid gland and diabetes, it’s more than an idle concern.

Hunt works up to 33 hours a week at $8.05 an hour at an area gas station. As a part-time employee, he does not qualify for health insurance. He makes just enough to pay rent, buy groceries and put gas in a car he borrows from his stepfather. He’s also taking courses which he hopes lead to a nursing degree from Davenport University.

There are thousands like Hunt in Michigan, their health care fate in the balance as legislators wrangle over Gov. Rick Snyder’s proposal to expand Medicaid coverage. Snyder’s plan to add an estimated 470,000 uninsured low-income individuals to Medicaid by 2021 stalled last month in the face of conservative resistance in the Republican Legislature.

Advocates say failure to enact expansion would do more than undermine medical care for the uninsured, but also assure that Michigan hospitals will rack up more unpaid bills — costs that are ultimately passed on through higher charges and escalating insurance premiums.

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“The Medicaid expansion is a very smart way to go,” said Laura Appel, vice president of federal policy and advocacy for the Michigan Health and Hospital Association.

She noted that MHA figures show that in 2011 Michigan hospitals furnished nearly $1.9 billion in uncompensated care. Expanded Medicaid, while not a panacea, “will help alleviate that,” she said.

Appel also argued that it also would lead to better health care, by promoting preventative medical practice and regular contact between patients and physicians and other health-care providers.

“You are ultimately going to have better outcomes,” she said.

Evidence for that, however, remains in dispute. A study released in May by the New England Journal of Medicine found mixed results in a comparison of a group of Oregon residents covered by Medicaid and a comparable group that was uninsured. It found that expanding Medicaid coverage “generated no significant improvements” in a variety of physical health outcomes. It did find a reduction in cases of depression and greater financial security among those on Medicaid.

Who will be affected by Medicaid expansion?There are nearly 1.2 million uninsured residents in Michigan, according to a 2013 analysis by the Michigan Department of Community Health. Wayne County led with 277,663 residents, followed by Oakland County with 117,460, Macomb County with 96,541 and Kent County with 73,099.

Snyder frames expansion as a prudent reform to the health-care system that would save money for both the state and health care providers. He projected general fund savings of $206 million in 2014 and $1.2 billion in savings through 2020. The savings stem from patients who now receive mental health services paid by state general funds. These patients would be covered under Medicaid expansion.

Under terms of the Affordable Care Act, the federal government is committed to pay full cost of Medicaid expansion from 2014 through 2016. Its share would fall to 90 percent by 2020 with states to pay no more than 10 percent after that.

Snyder proposes banking half of projected general fund savings to compensate for added state costs that accumulate after 2016. An analysis by the Senate Fiscal Agency projects that a “crossover point” – where costs exceed savings – will occur anywhere from fiscal year 2023 to FY2036.

Who's on Medicaid now?

According to the state, Medicaid covered about 1.8 million residents, as of April, including nearly 1 million children, 287,298 disabled and 108,672 elderly.

Though more than half of total recipients, children accounted for just 25 percent of total cost as of fiscal 2012. Disabled adults accounted for 39 percent of cost, aged residents 19 percent and parents and caretaker adults 15 percent.

Medicaid’s total cost in Michigan in FY2012 was $12.9 billion, including $8.5 billion in federal funds and $2.4 billion in state general funds and general purpose funds, reports the Department of Community Health.

The expanded pool of Medicaid recipients would encompass low-income, able-bodied parents and adults who have no children and earn up to 133 percent of the federal poverty level. Medicaid now covers individuals making up to $4,020 annually and families of four up to $8,713 annually.

Medicaid expansion was a key piece to health-care reform passed by Congress in 2010, projected to add 17 million U.S. residents to its health-care umbrella. But the U.S. Supreme Court in 2012, in upholding most of the act, struck down its mandate to expand Medicaid. It left that decision to states.

Since then, about two dozen states have either rejected expansion or are leaning against it.

The costs of the uninsured

While he would welcome the health security expanded Medicaid could offer him, Grand Rapids resident Hunt said he hopes to have coverage of his own within four years.

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“Maybe you will have a better job,” he said.

But until then, he is at the mercy of events beyond his control. He recalled his hospitalization in December at Metro Health Hospital in suburban Grand Rapids for a diabetic attack.

“It ran me $12,000. They wrote off that bill,” he said.

Hunt said he owes about $515 on another hospital bill that he is still paying off. He has a prescription to regulate his thyroid gland that he can’t afford to fill.

“It costs $100 a month. I can’t afford it so I don’t get that one,” he said.

A Grand Rapids physician who treats both the uninsured and those on Medicaid said choices like that, forced by lack of coverage, can be costly.

“A patient I can think of ended up having a stroke,” recalled Thomas Platt, chief medical officer for Cherry Street Health Services, a West Michigan nonprofit offering comprehensive health services to low-income children and families.

“Had that patient been able to get in for the right medication and services, that was a totally preventable situation. There was a very good chance that stroke never would have happened. It’s a big issue. Patients say, ‘Do I get food, do I pay my rent or do I pay for my medication?’”

Platt cited another patient with a painful foot condition whose lack of coverage jeopardizes both her health and job:

“She has plantar fasciitis and no medical coverage. The surgery to correct this is about $4,500. I am afraid she is going to lose her job because she is walking on a hard surface all day. There is simply no other way of getting that corrected.”

Grand Rapids residents Aurelio and Maria Salto make about $26,000 a year in joint income, from his work as a carpet installer and her home business selling kitchen ware. With a daughter, Elizabeth, 18, they are near the income cutoff for expanded Medicaid. The Saltos say they cannot afford health insurance.

And with virtually no savings, the Saltos think twice before seeing a doctor. They are still paying off part of a $2,400 medical bill Maria, 53, incurred from a lifting accident at an earlier job in a factory. Aurelio, 44, recalled that he underwent a recent physical exam and was told to get follow-up blood and other tests. He deferred.

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Speaking in Spanish, with his wife translating, Aurelio said, “I didn’t go because I knew it would be a bigger bill.”

Ted Roelofs worked for the Grand Rapids Press for 30 years, where he covered everything from politics to social services to military affairs. Roelofs wrote this for Bridge Magazine, which is part of the Center for Michigan.